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Reduce restraint use for mental-health patients
Do quick assessments
Adrienne Jones, RN, an ED nurse at Providence St. Vincent Medical Center in Portland, OR, says that ED nurses used to see about five to 10 mental-health patients a day, but are now seeing twice as many. ED nurses use these practices to decrease restraint use:
A medical screening examination, an examination by a social worker, and a safety assessment for patient and staff is done.
Each patient who presents to ED nurses with a mental-health complaint is asked, "Have you had thoughts about hurting yourself or others," "Do you have a plan and/or means," and "Have you made previous suicide attempts or gestures?"
"Triage nurses should use clinical judgment, as they do in determining medical risk. Err on the side of caution," says Jones.
Mental-health patients may present with medical issues, and may not be there for a mental-health issue, warns Jones. "Their mental-health issue may distract you, and cause a serious medical issue to be missed," she says.
A patient may have a headache, fever, or cough unrelated to the mental-health issue, she adds, and this can worsen a patient's mental-health crisis. "When determining risk assessment and triage category, take into account the family's, caregiver's, and police account of the incident," she says.
You may learn that your patient made previous suicide attempts, says Jones, or that he or she has a specific plan to harm himself or herself, such as carbon monoxide poisoning.
A SBARR form is used for ED mental-health patients.
"The form is used from the time they hit the door until disposition," says Jones. "It is updated as things change, much like the old kardex." [A protocol for intoxicated patients in the ED is included.]
When a patient is handed over from triage to the primary nurse, the SBARR form is used, says Jones. "The same information that the triage nurse has obtained needs to be passed to the primary nurse," she says. "When a patient is brought from triage, the handover must be done nurse to nurse."
All ED nurses are trained in de-escalation of violent patients.
A four-hour class, Prevention and Management of Assaultive Behavior (PMAB), is given by mental-health nurses and technicians, and covers assessment, de-escalation techniques, and what to do if attacked by a patient, says Jones.
"Patients coming in who are currently violent are assessed prior to coming into the building," says Jones. "By emphasizing PMAB instead of a code gray, the mindset of those involved is to promote the least restrictive intervention possible."
All mental health patients are dressed in green scrubs.
"The green scrubs alert all staff, including the doctors, that this patient is in the ED for mental-health issues," says Jones. "If we see a patient wandering the halls or attempting to go out of the ED, we can stop them before a crisis occurs, and get them back to their room." (See related stories on medication administration and the patient's home medications, below.)
For more information on restraint use in the ED, contact:
Adrienne Jones, RN, Emergency Department, Providence St. Vincent Medical Center, Portland, OR. Phone: (503) 216-2361. Fax: (503) 216-2330. E-mail: firstname.lastname@example.org.
Fast assessment, meds can avoid restraints
Abigail Coffin, MSN, PMHNP-BC, ANP-BC, a psychiatric nurse practitioner in the ED at Duke University Hospital in Durham, NC, says that quick assessments and medication administration are two keys to avoiding restraint use.
"If the patient has a history of aggression, get the PRNs ready," says Coffin. "Offer [oral medications] first, so the patient feels some sense of control. If the [oral medication] is refused and the patient is agitated and dangerous to self or others, force intramuscular medications."
Give medications immediately when a patient starts to become agitated, advises Coffin. "If they cannot redirect themselves and calm down, there is no need to wait," she says. "I often see patients medicated well beyond the point of no return. Treat the agitation well before restraints are required."
All of Duke's ED nurses have received training in de-escalation, and how to defend oneself if necessary from an aggressive patient, adds Coffin. "The number of restraints and seclusions has dropped dramatically," she reports. "We also do not require the use of our police nearly as much."
Abigail Coffin, MSN, PMHNP-BC, ANP-BC, Emergency Department/Psychiatric Evaluation Unit, Duke University Hospital, Durham, NC. Phone: (919) 681-4402. E-mail: email@example.com.
Keep psychiatric patients on their home meds
If a psychiatric patient is being held in your ED, keep the patient on the medications he or she is supposed to be taking, advises Abigail Coffin, MSN, PMHNP-BC, ANP-BC, a psychiatric nurse practitioner in the ED at Duke University Hospital in Durham, NC.
"Often, the home meds are forgotten. Do not stop them because they are in the ED," says Coffin. She adds that due to lack of available inpatient beds on psychiatric units in North Carolina, psychiatric patients can wait in the ED for up to a week.
If a schizoaffective patient is on [divalproex sodium] 1500 mg PO QHS and [risperidone] 2 mg PO QHS to control agitation, mania, and psychosis, for example, it is important to continue these medications and not miss doses, says Coffin.
"It is also important to know if a patient cannot take [haloperidol] due to a history of a severe dystonic reaction, or if they cannot take [lorazepam] due to severe disinhibition," she notes.